Digesting the difficult decisions of development

Menu

Category Archives: Africa

The Ethiopians appear to be close to finalizing construction of a large hydroelectric dam on the Omo river, primarily to generate power but also to support local irrigation efforts. Over the past five years the project has received substantial foreign financing and investment by China and indirectly by the World Bank. However, there appears to have been little consideration of the potential downstream impacts: the Omo river feeds Lake Turkana, which is a source of livelihood for a large number of communities in northern Kenya. The possibility that the lake may be partially drained is obviously upsetting a lot of people, although it does not seem that the Kenyan government is making a big fuss over the project.

This is a typical problem of negative externalities: the Ethiopians aren’t factoring in the welfare of Kenyan Turkana residents in the decision to build the dam. There’s actually some research showing that this is a common problem. From a recent World Bank paper by Sheila Olmstead and Hilary Sigman:

This paper examines whether countries consider the welfare of other nations when they make water development decisions. The paper estimates econometric models of the location of major dams around the world as a function of the degree of international sharing of rivers. The analysis finds that dams are more prevalent in areas of river basins upstream of foreign countries, supporting the view that countries free ride in exploiting water resources. There is weak evidence that international water management institutions reduce the extent of such free-riding.

By their very nature dams generate inequality in the flow of water between upstream and downstream areas. It is easier to pay the cost of hurting downstream communities when they are are in a different country (hey, they don’t vote for you). Ergo, countries are more likely to build dams when the costs are external.

It would be interesting to see what mitigates these effects – it is possible that Kenya’s relative indifference is due to lack of political power on the part of the northern tribes. Are dams with substantial cross-border costs less likely in areas where the proximate ethnic group is quite powerful?

Within months, Heaton was journeying through the desolate southern stretches of Egypt and into an unclaimed 800-square-mile patch of arid desert. There, on June 16 — Emily’s seventh birthday — he planted a blue flag with four stars and a crown on a rocky hill. The area, a sandy expanse sitting along the Sudanese border, morphed from what locals call Bir Tawil into what Heaton and his family call the “Kingdom of North Sudan.” There, Heaton is the self-described king and Emily is his princess.

Uh, what?

Heaton says his claim over Bir Tawil is legitimate. He argues that planting the flag — which his children designed — is exactly how several other countries, including what became the United States, were historically claimed. The key difference, Heaton said, is that those historical cases of imperialism were acts of war while his was an act of love.

At 200,000 hectares, this partially qualifies the, uh, Kingdom of North Sudan to be counted as a land deal in the Land Matrix. This dude even wants to use the land for large scale agriculture:

The next step in Heaton’s plan is to establish positive relationships with Sudan and Egypt by way of converting his “kingdom” into an agricultural production center as his children, especially Emily, wanted.

Malawi will have its next presidential election in just a few days. Kim Yi Dionne posted some photos of the four most prominent presidential candidates. One stood out to me:

I’m a little unclear as to what “Generation Change” comprises. If Atupele Mulizi is indicating that his election would essentially be a changing of the guard, then this slogan is pretty appropriate, given that Atupele is the son of former president (and all around disaster) Bakili Mulizi. But if, by “generation change”, Atupele is indicating that he is bringing something new to the table, then this is more than a little awkward. Similarly, the DPP candidate Peter Mutharika is the brother of the late president Bingu wa Mutharika.

In other news, Joyce Banda’s campaign slogan relies on good old fashioned promises of more transfers to the rural population, with “Continued Fertilizer Programme. More Crops, More Food.” Where have I seen this strategy before?

“Look, I’d had a lovely supper, and all I said to my wife was: “That piece of halibut was good enough for Jehovah.” “Blasphemy! “”

Large crowds are inherently scary. Not, perhaps at first glance, but those of us that live in large cities do so under the assumption that while crowds are somewhat chaotic and have the potential for danger, they will never be intentionally malevolent, at least not towards us. Yet there is still an unease there, of the type that underlies the kind of horror frequently employed in post-apocalyptic zombie films or John Carpenter flicks, that very quickly the crowd can turn against you.

Perhaps this is not totally unreasonable source of anxiety – while most violence in London (where I’ve recently started living) tends to be of the individual-on-individual sort, mob violence is more frequently a reality for many living in developing countries. Take, for instance, this new report by the incredibly prolific NGO Twaweza on violence in Tanzania. Drawing upon a nationally-representative phone survey, one of the most striking results is deaths due to mob violence appear to be more common (or are as commonly-perceived by respondents) than ordinary murders:

In fact, as many people are killed by mobs as by ordinary citizens, police and the national army combined. If we consider mob violence to be a form of extra-legal justice, imagine a government which executes more people than those who commit murder. While these figures are based on perceptions and should be taken with a grain of assault, it’s worth noting that forensic investigations into violent deaths in Dar es Slaam reveal that at least 10% are due to mob justice, still a staggering number.

Yet, outside of the occasional hushed ex-pat dinner party conversation or resigned lamentations by locals, I’ve rarely hear people actually discuss the causes and consequences of mob violence in much detail (although as I write this I suspect that a reader will soon point out that something akin to a Journal of Mobbing Studies which I will have overlooked).Malawi, where I lived for some, seemed particularly afflicted with mob violence centred around automobile accidents, where the drivers of cars found to be at fault were often assaulted, and sometimes killed. This happened with enough frequency to create a culture of “fleeing the scene,” where drivers who were not even directly connected to an accident drove off for fear of being blamed and attacked (this was the basis for a film I shot whilst living there). I began thinking about the issue again when, recently, one of the respondents in a survey I’m helping run in Dar es Salaam was killed by a mob after (purportedly) murdering another resident.

What leads to mobbing and why does it appear to be more prevalent in societies with dysfunctional institutions? Let’s take the armchair economist position for a moment: it would probably be fairly easy to write down a herding model where people update their beliefs about a person’s guilt based on the behaviour of others. Person 1 decides, for whatever reason, that the accused is guilty, person 2 updates his/her beliefs based on person 1’s belief, and so on, until you have a mob which is convinced that the accused is guilty. If you combine that with a utility function that inversely weights the disutility or ‘guilt’ one might feel from being personally responsible for a death (I take comfort in knowing I probably didn’t throw the fatal stone), it’s easy to see how mobs might easily form in a context where punishment would otherwise be uncertain.

While this sort of explanation is rather intuitive, I find it a bit unsatisfying for three reasons: i) it ignores the drivers of the probability of punishment in the counterfactual and ii) it assumes that mob behaviour is solely defined over the desire to inflict justice on the guilty. It also tells us nothing about why people are more likely to be stoned to death in Dar es Salaam than, say, Myrtle Beach. A couple of thoughts:

i) What happens if we don’t stone people to death? Most socio-cultural explanations share a similar premise: people rely on mob violence precisely because they do not trust the formal justice system to get the verdict right. If the police and judiciary are capable of finding and punishing the right person, our need to rely on selection-via-herding decreases. If this is true, then strengthening the formal justice system should reduce mob violence. This falls apart if people can selectively engage the formal system – if mob justice isn’t just about guaranteeing some form of punishment, then perpetrators may still choose vigilantism over bringing in the police. This brings me to the next thought:

ii) Is this really about punishment? As with most social/political/economics concepts, Monty Python got there first: in Life of Bryan overzealous women disguise themselves with fake beards so they can throw stones at people for the fun of it. If mobs are primarily made up of young angry men, then we might begin to suspect this has more to do with the tendency for young, angry men to enjoy a bit of the ultra-violence.

Is there a quick fix here, other than waiting for the legal system to become strong enough to both reasonably guarantee punishment of those that commit the initial crime and those who engage in mob justice? Given the snowballing nature of mob violence, moving quickly to both disrupt the initial signal (that the accused must be guilty) and raise the cost of participation (a less extreme version of the Desmond Tutu method of mob justice defusal, perhaps). Do we need a roving band of mob-busters to save the day?

Or perhaps it is reasonable that mob justice is so infrequently subject to policy discussion – it is something which probably declines as countries get richer and their institutions grow more robust, so is it really deserving of too much scrutiny?

There wasn’t much for me to do when I first joined the Budget Division of Malawi’s Ministry of Finance back in 2006. My particular position had been vacant for almost a year, so it took a bit of time before the acting budget director grew accustomed enough to start diverting work my way. One of the very first things I worked on was an attempt to reconcile the difference between expenditure ceilings set by my department and actual reports of expenditure from the Accountant General’s department.

What complicated this process was the fact that the Accountant General had recently adopted an Integrated Financial Management System (IFMIS), essentially a comprehensive software platform for approving and tracking expenditure. A lot of promises came with IFMIS – the ability to track expenditure in real time and keep a tight leash on expenditure by line ministries. Yet, when I had arrived, the budget department had yet to fully adopt the platform, meaning that our (often fairly specific) budget ceilings had to be manually reconciled with IFMIS-generated expenditure reports.

I doubt that the budget director seriously believed that this greenhorn civil servant was really going to accomplish much with this work and probably saw the task as something to keep me busy while I grew more accustomed to my environment. Even so, I quickly noticed that IFMIS-generated reports seriously deviated from what was being approved by the Budget Division, sometimes even showing expenditure which was above and beyond what had been mandated by our department.

At my director’s prompting, I visited the relevant department at the Account General’s to request more detailed reports from IFMIS. The likely culprit was some of data problem, and I was curious to get to the bottom of it, seeing the whole exercise as a problem with some sort of technical solution. While the civil servants I spoke to at the AG were friendly enough and agreed to send me reports, upon my return to the Ministry of Finance it was later made clear to me that the AG wasn’t too fond of this unknown fresh-faced mzungu making random requests. Not long after, more pressing work diverted my attention, and this particular issue faded into the background.

Later, our own department grappled with the adoption of IFMIS. While technological solutions are frequently touted as solutions to institutional problems (this platform will eliminate corruption!), my experience was that without some basic level of capacity in place, even the most advanced platform was doomed to fail. Hence, if two government ministries can’t keep their budget tallies synchronised in Excel, they are unlikely to be able to get a more complex `black box’ system to work properly. This is problematic, because when finance systems don’t work properly, it’s very difficult to tell the difference between corruption and incompetence.* My feeling at the time that the discrepancies between the AG’s expenditure records were due to the latter, even though I heard the occasional, unsubstantiated whisper that someone at the AG was stealing money.

This was surprising to me, as there had been a fairly visible crack down on corruption and leakage during the first term of then-president Bingu wa Mutharika. However, it was widely recognized that during his second, more tumultuous term (which began after I had left the country), government systems became more porous and corruption become more common.

One might have expected things to improve upon Mutharika’s sudden death and the ascension of the pragmatic Joyce Banda to the presidency. Yet despite wowing a lot of donors and even some skeptics – including yours truly – her government seems to have inherited many of its predecessors failings: a recent scandal has broken out over implications that there has been substantial theft by employees of the Accountant General’s department, who exploited loopholes in IFMIS to siphon off money.

We tend to lump all dodgy dealings into the broad category of corruption, but there is a clear difference between institutionalised corruption, where political leaders divert resources towards their own benefit, and the kind of rampant theft which goes on when you have a leader who either is unaware of or cannot control corrupt practices. Banda’s situation clearly falls in the latter – given that she has, until very recently, ruled over cabinet of former members of Mutharika’s party as well as the opposition – she has always been in a precarious position and thus unable to fully keep everyone in her government in line.

The scandal hasn’t been completely bloodless. The recently-appointed director of the Budget Division, Paul Mphwiyo, was nearly shot to death following his attempts to close the loopholes leading to theft of public resources. I knew Paul during my time in Malawi: he was serving as an assistant budget director when I was working for the Ministry of Finance, although we didn’t often work closely together. Let’s hope he recovers quickly and his assailants are eventually apprehended, although I have my doubts about the latter.

For those wanting to keep tabs on the scandal, Kim Yi Dionne remains an excellent source for recent Malawi news and analysis.

*This confusion can be easily exploited.

Update: This post got a little more attention than I thought it would, so just wanted to add a little addendum.

I want to be cautious about drawing too many conclusions from my (very brief) interaction with the AG’s system – the Cashgate scandal is another animal entirely. In weighing the corruption or incompetence possibilities, it’s highly likely that my situation fell in the latter. I just felt it was worth noting that these things aren’t always clear, and that there was a bit of an administrative wall between the Account General’s Office and the Budget Division of the Ministry of Finance (they were, at least when I was there, separate `votes’ on the cabinet and in separate buildings.) Also, for the sake of my former department, I want to make it clear that this thing at least seems to be entirely of the AG’s making, and I saw nothing in the Budget Division during my time there that suggested any wrongdoing of this sort.

“Where the hell is the Jaeger?” “Oh the government couldn’t really figure out how to evaluate the giant robots-fight off giant aliens programme, so they basically just do cash transfers now.”

Kevin Grier grumbles about the IDA, arguing that its investments couldn’t possibly stack up to cash transfers:

The last 3 year replenishment of IDA was for 49.3 billion dollars. So for a decade of IDA, we can use 150 billion dollars as a cost number. People, for $150 billion dollars, you could give 75 million people each $2000 in cold hard cash. From my point of view, that sounds a lot better than giving them “access” to services. Now sure, there are aid agencies worse than the IDA (phone call for USAID), but there is nothing in Mombrial’s post that backs up his claim that the IDA is a good investment, and in my opinion, it’s actually a bad investment relative to unconditional cash transfers.

Even without the growing body of empirical evidence indicating that just giving cash is an incredibly cost-effective way to increase welfare, there is an extremely compelling theoretical case to be made for cash transfers. Poor households have preferences (replace these with `needs’ if you are so inclined, although there are important distinctions between the two), and no one will ever have better information on these preferences than these households. Transferring households cash allows them to best allocate these new resources to meet these preferences – otherwise, we run the risk of wasting resources on stuff that households just don’t want.* Combine this with the fact that cash transfers are getting quite easy to make, especially in the era of mobile money, and they appear to be a reasonable standard by which to compare all other interventions.

Yet, the most ardent supporters of cash transfer programmes often forget that many societies (read: all societies) are still struggling with pretty severe collective action problems which inhibit the provision of public goods. It’s far from clear that distributing cash will solve these problems: if a village of people haven’t banded together and produced a well-functioning school by now, although giving them cash certainly increases their purchasing power to do so, it’s unlikely to solve the basic collective action problem resulting in the failure to produce the school.

This is important, as there are a range of public goods (or semi-private goods which have substantial externalities) which we can imagine might increase welfare a great deal more than a cash transfer of equivalent cost: schools, health facilities, roads, a functioning police force. Basically, any semblance of a local or national state. How many of you would vote for your own government to transfer its entire budget evenly across the population and then shut down all its operation for good? It certainly would make it easier to pay the rent next month, if your apartment complex hadn’t been burned down by the marauding hordes yet.

Now, if the collective actions problems we care about have already been solved by the market, we should be less worried. Despite a steady flow of misinformed rhetoric from NGOs suggesting that private schools in developing countries are a distraction, there is a great deal of evidence suggesting that in settings where the state is failing to provide quality schooling, private schools present a reasonable (and probably strictly superior) alternative for poor families. In these settings, unconditional cash transfers should be enough. However, there are going to be a lot of contexts where markets are not filling these gaps. For example, rural health clinics tend to be the preserve of government or NGO work, rather than the private health sector, so the effect of income on health outcomes in these contexts is going to be more complex.

The hypothesis “is intervention X better than cash?” is relatively easy to test for a whole slew of interventions: run an RCT and see if this is the case. Yet, while development economists are getting quite good at making and replicating these comparisons for private or small-scale interventions, many of the large public-good investments that have the potential for a large payoff remain difficult to convincingly empirically evaluate (I am somewhat optimistic that we will get there, but we’re certainly not there yet). The current bias towards cash represents not only a positive assessment of the returns to these types of interventions, but also a preference for interventions that can easily be shown to work.

Yet we know that public goods matter and that cash-transfers, to the extent that they cannot be taxed by the state, are unlikely to help in this regard. Multilateral lending/aid organisations like the IDA tend to focus more on projects which have some public good element, such as infrastructure. Whether or not these organisations are any good at producing successful, cost-effective projects is certainly a question we should be asking. But the choice that Grier presents us with is a false one: that we must choose between wasteful public good spending and cash, as if the cash-only equilibrium is the only one that could ever make any sense.

I am frequently guilty of wheeling out the “but is it better than cash?” argument whenever I see an intervention which looks wasteful or too paternalistic** for my taste, but we should be cautious not to use cash transfers as the appropriate gold standard for every intervention. There are plenty of public-good-type interventions which are (currently) hard-to-measure but important. Whether or not aid donors and governments are any good at funding these interventions should be the starting point for the discussion.

*I’m ignoring a lot of potential problems here by using households instead of people, as well as ignoring issues with time-inconsistency, etc, because I want to focus on one particular argument in this post.

**There are those that doubt the efficacy of unconditional cash transfers due to concerns over the ability of households to discern what they should be spending the money on. These concerns are not entirely unfounded – we are all subject to a variety of cognitive biases which can lead to suboptimal decisions. I choose to ignore these concerns here, not because I don’t think that they apply, but because I’m pretty skeptical that aid agencies and charities would be better at determining optimal private expenditure patterns than households.

“Sol, we’re new here and don’t really know anybody, so get over to Swearengen and secure us a title deed to some property.”

Things have been a bit quiet recently – part of this is due to a lengthy field-based ethnographic research trip focused on the interaction between late 80s and early 90s UK dance music and Croatian culture. I also was tied up by the always-impressive `Growth Week‘ held by the International Growth Centre Growth at LSE. I’ll let you guess which was more fun.

So let’s start with some blatant self promotion – I’ve got a new working paper out. Here’s the short, short version: most unplanned settlements or `slums’ in most of SSA are dominated by informal tenure, where your right over land is more likely to be determined by customary law, social connections, or ad hoc semi-formal methods of establishing occupancy, than it is by a formal land title. Some households are going to have an easier time of securing their tenure through informal means, others who face higher costs to doing so might be more likely to accept property rights provided by the state. I examine this by looking to see whether or not households in Dar es Salaam which are ethnically-isolated (surrounded by neighbours from other tribes) are more likely to buy property rights offered by the Tanzanian government.

For more detail, head over to the CSAE blog, where I talk about the paper in a little more detail.

I’ll leave you with an image which sums up all the fears and uncertainties of tenure in slums: a landowner on Oxford Street, Accra, who desperately wants to avoid the sale of his/her property (thanks to Elwyn Davies for this photo):

Once plentiful, land has become scarce, and competition fierce. The district population has been growing fast………. Youths struggle to find any land to sustain their new families. In some villages, it is difficult to get even one hectare. In the village of Amanikrom a young man eager to farm could only get a fifth of a hectare. So the landless youth work their way up by starting as labourers or sharecroppers. In the past, sharecropping attracted migrants only from other parts of the country. Today, young members of the landowning family have to resort to sharecropping too. Meanwhile, much land is in the hands of absentee landlords who work in Accra and use part of their wages to pay for agricultural labourers.

That is from Lorenzo Cotula’s recent book on land grabbing in Africa. For those of you who consider this to be a third world problem: read the segment above one more time, but replace “land” with “housing”, “fifth of a hectare” with “studio apartment”, “sharecropping” with “renting”, and “agricultural labourers” with “council-approved extensions.”

“Sorry Kah-El, your field trip to earth has been denied – instead we’re going to channel the funds into building more schools on Krypton.”

Michael Kevane grumbles about the cost of Obama’s upcoming ten-day trip to Senegal, Tanzania and South Africa, which is projected to cost a hefty $100 million, pointing out the money could be put to better use:

I always like to do the basic math. We (FAVL) set up village libraries for about $15,000 and that covers about five years of operations until the office of the mayor can take over. Let’s say there is no book renewal or much maintenance afterwards… still you get about 10 years of 500 villagers reading a lot. How many villages? Well, 100 million divided by $15,000 is 6,666… so village libraries could be established pretty much across the entire Sahel, for this one ten day trip… What do you think about that? Maybe President Obama can just make a Skype call instead? Oh wait, those are tapped by NSA.

I sympathise with Kevane’s argument here and find it difficult to swallow that a presidential visit should cost $10 million a day. That said, it’s very difficult to assess the value of diplomatic trips, and using a strict “we could have spent that money on my favourite intervention X”, might not be the most appropriate way to judge every single policy decision. This may be an entirely useless bit of PR (and I would guess it it probably will be), but it could also pay off in unknown ways for both the US and for the countries Obama is visiting. For example, some have suggested that Obama’s visit to Ghana several years ago boosted tourism (although these things are, frankly, pretty hard to pin down). Actually, given that someone has already done research on the effects of papal visits, I’m surprised that no one appears to have done any work on the economic impact of international presidential visits on receiving countries.

It’s also worth pointing out that budget ceilings were probably set a long time ago: this exorbitant trip is likely pulling a money away from other State Dept/intelligence budgets (strongly suggested in this Washington Post article also highlighting the price tag on the trip). However, if we’re going to be moving into fantasy territory, I can think of more reasonable targets than establishing closer ties to African countries: why don’t we pull out of fucking Afghanistan right now and spend all that money on development aid?

Thanks to three randomised controlled trials held in several sub-Saharan countries, it is now fairly clear that male circumcision leads to a sizeable reduction in the probability that a man will go on to contract HIV. The treatment effect of getting snipped is nothing to laugh at: most estimates put it at a 50-60% reduction in risk. I’m not sure that anyone has actually ever bothered to do a cost-benefit analysis, but as a policy it seems like a no-brainer to the global health community, who has been quick to support it as an effective means of battling the AIDS epidemic.

Like with most `new’ technologies which have been shown to be effective in a near-laboratory setting, the next step was to roll-out and scale up the intervention. Circumcision campaigns with very ambitious targets kicked off in several SSA countries, many of them supported by PEPFAR. Several years down the road, it seems that many countries are struggling to get anywhere near their goals, as is the case with Swaziland, where only 20% of the targeted demographic were `reached’.

Surprise, surprise, the biggest issue seems to be that of low demand: men in Swaziland don’t appear to be particularly keen to forfeit their foreskin, for a host of reasons, ranging from personal doubts over efficacy, to concerns over pain, to worries about witchcraft:

“That’s also what I wanted to know, and they wouldn’t tell me – what happens to my foreskin once it is cut off?” said Mduli.

Health Minister Xaba alluded to this when he told the Times of Swaziland, “Some men feared that the foreskin could end up in wrong hands, being used by some unscrupulous people for their ulterior motives.”

The lack of coverage in the Swaziland campaign seems to be indicative of similar campaigns in Kenya, Uganda and Zimbabwe: there is initially a surge in demand as large groups of exceptionally-enthusiastic men line up to be circumcised (similar to the zeal that the Merry Men in Robin Hood: Men in Tights show before Rabbi Tuckman reveals to them what circumcision actually is), but eventually demand levels off and most of the population remains untreated.

This problem isn’t unique to circumcision – there are a lot of `treatments’ which have shown to be effective using rigorous methods, but have failed to scale due to lack of demand. Unfortunately, most randomistas (rightfully) spent there time trying to establish that treatment effects exist before worrying about treatment demand, but then fail to spend as much time figuring out how these things should be rolled out; although sometimes both questions can – to some extent – be answered at once if we are randomly inducing people to take up a treatment, rather than randomising the treatment itself. These questions are not only important for a policy perspective, but they might also give us more insight as to what the actual real or perceived benefits are once we move out of the experimental setting.

Circumcision is a particularly difficult area in this regard. We know very little about how to increase demand for circumcision. Can you tell me what a man’s marginal willingness-to-sell a foreskin is? It is also a difficult subject to cover dispassionately – I suspect that for the already-circumcised, the marginal willingness-to-pay for a foreskin is closer to zero. For many of the uncircumcised, the marginal willingness-to-pay keep one’s foreskin is probably very, very high. Given the extensive roll-out of circumcision programmes in southern Africa, there will be some incentives to experiment with ways of creating demand here. For example, Berk Özler at the World Bank has suggested that it might be time to start paying men to get circumcised (or at least begin compensating them for lost wages).

Yet, this brings us to the second problem with the roll-out of circumcision programmes as well as the different methods campaigns might employ to entice men onto the chopping block. We know that, within a relatively short time frame, circumcision significantly reduces a man’s chance of contracting HIV. Yet we know substantially less about how subsequent behaviour might play a role in overall HIV risk down the road. Many have been concerned about Peltzman effects, the tendency for people to do more of an activity when it becomes (what the medical literature is calling behaviour risk compensation). As some have pointed out, even if circumcised men don’t increase their sexual activity enough to offset the effects of circumcision, the effect of transmission on women (who are not protected by male circumcision) will go unmitigated. There hasn’t been nearly enough work done on the behavioural effects of circumcision, but at least one paper, which I wrote about some time ago, has suggested that Peltzman effects are, on average, not a problem. However, the same paper found a bifurcation in behaviour: men who had been circumcised AND believed in the treatment effect reduced their risky sexual behaviour, but those who had been circumcised and did not believe in its effectiveness increased their risky sexual behaviour.

Consider this result in light of some of the proposed methods to get more men circumcised: methods which do not actually involve changing beliefs, such as paying people to get circumcised, might lead to more men who don’t believe in the power of the snip signing up, precisely the men who will end up increasing their risky sexual behaviour. This is quite scary.

I’ve written before about how I’m deeply sceptical about the success of mass-circumcision campaigns. However, even a sceptic wants things to be done right if they’re going to be done at all. It shouldn’t be so astonishing that most men aren’t dashing to the clinic to receive a circumcision. The global health community will need to do more rigorous research on how to get men into clinics, but at the same time that research should be leveraged to make sure that these campaigns are having their intended impact.